Overview
Arterio-biliary fistulas are rare, high-risk connections between biliary and vascular structures, often resulting from iatrogenic injury, chronic infection, or trauma, leading to hemobilia and potential biliary complications 123.Diagnosis
Clinical Presentation: Severe melena, cholangitis, jaundice, and elevated bilirubin and alkaline phosphatase levels 23.
Diagnostic Imaging: Hepatic artery angiography is crucial for identifying pseudoaneurysms and fistulas 2.
Endoscopic Procedures: Endoscopic retrograde cholangiopancreatography (ERCP) can diagnose biliary-vascular fistulas and facilitate nasobiliary drainage 3.
Histopathologic Confirmation: In animal models, histopathologic evaluation helps understand the evolution stages of fistulas 5.Management
First-Line Treatment: Endovascular embolization using soft and biodegradable materials like histoacryl glue or thrombin 1.
Adjunctive Therapies: Combined endovascular and endoscopic biliary tract revision may be necessary for persistent cases 1.
Biliary Drainage: Nasobiliary drainage can resolve symptoms and jaundice in acute fistulas 3.
Embolization Complications: Monitor for complications such as coil migration and subsequent biliary duct revision 1.Special Populations
Iatrogenic Injury: Common in patients undergoing biliary interventions, requiring careful procedural technique 12.
Elderly and Comorbidities: Higher risk of complications; individualized management considering overall health status is essential 1.Key Recommendations
Endovascular Embolization is the preferred initial treatment for arterio-biliary fistulas using biodegradable materials (Evidence: Strong 1).
Combined Endovascular and Endoscopic Approaches may be necessary for complex cases requiring biliary tract revision (Evidence: Moderate 1).
Nasobiliary Drainage should be considered for acute biliary-vascular fistulas to manage symptoms effectively (Evidence: Weak 3).References
1 Stefańczyk L, Polguj M, Szubert W, Chrząstek J, Jurałowicz P, Garcarek J. Arterio-biliary fistulas: What to choose as endovascular treatment?. Vascular 2018. link
2 Rai R, Rose J, Manas D. An unusual case of haemobilia. European journal of gastroenterology & hepatology 2003. link
3 Verhille MS, Muñoz SJ. Acute biliary-vascular fistula following needle aspiration of the liver. Gastroenterology 1991. link90415-h)
4 Peven DR, Yokoo H. Bile pulmonary embolism: report of a case and a review of the literature. The American journal of gastroenterology 1983. link
5 Quisling RG, Mickle JP, Ballinger W. High-flow, aortocaval fistulae: radiologic and histopathologic evaluation in a rat model. AJNR. American journal of neuroradiology 1983. link